Continuing medical and tehnological advances have resulted in more prematurely born infants living than ever before, and current research has shown that 25% of those infants carry mild to moderate disabilities. In addition, there are large numbers of young adults who suffer brain damage and cognitive dysfunctions caused by head injuries. It is estimated that more than seven million children between the ages of six and twenty-one, and approximately twenty million adults over twenty-one have either mental retardation, learning disabilities, or traumatic brain injuries with attendant cognitive deficits. One category of cognitive deficits are known as executive dysfunctioning.
Executive Functions are those functions which significantly determine the extent to which a person exhibits appropriate and responsible adult behavior. They enable individuals establish priorities, make decisions, or alter a course of action when intervening circumstances require action modifications. Of the cognitive defects that impact daily functioning of people with neurological deficits, executive functions effect the everyday personal, interpersonal, and work related behaviors in ways that critically impact interpersonal relationships and functional abilities in the areas of independent living and work.
Four major components of executive functioning are volition, planning, purposeful behavior and effective performance.
Volition is will, agency, choice that emanates from knowing what one wants and contains the motivation to gratify them.
Planning reflects one's ability to plan and execute a sequential series of goal directed behaviors. Competent planning demonstrates skills in organizing, thoughts and plans, securing and working with the necessary people, equipment, tools, etc. Effective planning also requires mental flexibility when unexpected obstacles intervene.
Purposeful behavior reflects the ability to initiate purposeful sequentially executed behaviors that demonstrate awareness of self, others, and the environment. It involves the person's capacity to employ flexibility when circumstances require modifications in goal and adoption plans.
Effective performance indicates the capacity to observe, correct, and regulate one's own behavior, affect speed of operation, and thoroughness of: performance. Attitude and judgment or performance thoroughness are important to observe and assess. (Lezak, 1995, PP 650-677)
Disorders of executive functioning can be reflected by inadequate self care skills, difficulty, managing or spending money wisely, and problems initiating and completing intentional, goal-directed, self monitoring actions, There usually is evidence of all or some of the following deficiencies:
1. Problems with volition and initiating behavior can be reflected by a lack of motivation, the inability to initiate and intentional action, and may involve difficulties in executing and sustaining focused, goal-directed actions. There often is a lack of self awareness and sensitivity towards others. PA0 2. Planning deficits are often related to poorly organized action sequences that include the necessary people and resources to reach the intended goal. The insufficient awareness of the relationship between planning, actions and outcome poses problems when these individuals are confronted with the unanticipated repercussions of their poor planning and inability to implement alternative strategies. PA0 3. Inability to execute, purposeful behaviors is characteristically reflected in impulsive actions, disinhibited speech and/or conduct where the person is unable to contain irrelevant or reflexive responses. Difficulties also occur when routinely executed functions no longer are appropriate and the person cannot modify his plan or behavior according to those changes (Levinson, 1996). PA0 4. Ineffective performance refers to the difficulty a person has observing, modifying and regulating his/her behavior. PA0 5. Perseverations are behaviors or verbalizations which, driven by internal, unconscious and/or neurological determinants, continue well beyond interpersonal and/or circumstantial appropriateness. PA0 6. Impulsive behaviors are those that occur without regard to contextual or social appropriateness without regard for consequences. PA0 7. Diminished self and interpersonal awareness exists when a person is unaware of how his/her behavior impacts another person, is (in)appropriate to the Context. and demonstrates little self awareness as well as reduced capacity to alter behavior or acknowledge it.
Example 1: A person is aware of the need to shower. brush teeth, comb hair, and wear clean clothes, but is unable to do this regularly unless another person remains present and directs each step of the morning hygiene and personal care routine. PA1 Example 2: A man's inability to stop flooding every new girl friend with gifts, invitations, and phone calls results in his inevitably losing every newly initiated relationship. The man always experiences sorrow and remorse for causing the woman enough distress to break-up with him. However, regardless of the guidance or reminders of behavioral rules, the man can not refrain from resorting to the same behaviors when starting out with a new girlfriend. PA1 Example 3: A woman wants to complete her college education. She registers for courses that are too demanding and beyond her academic skills. She is unable to attend classes, maintain a part time employment, and she refuses any advice and suggestions from college counselors or professionals. Their recommendation that fewer and less demanding courses be considered is ignored and the woman drops out of school, blaming her failures on the teachers and "system." PA1 Example 4: A person wants to live in his own apartment and "run his own life." However, he makes no attempt to earn a steady job which would enable him to afford an apartment and the self maintenance expenses. While he sees the relationship between wanting an apartment, needing the money to pay rent, and getting a regular paying job, he makes no independent attempt to look for a job or contact a vocational rehabilitation agency. PA1 Example 5: A young clerical employee talks with his financial tutor about taking a week's vacation to Disney World. He wants to travel by airplane, stay in a hotel, and visit the park. Discussions reveal neither an awareness of the planning process, nor a realistic idea of the involved costs. His desire to contact airlines, hotels, and the park without assistance were initially respected. A lack of results led to the counselor and the employee into developing a written money saving and planning process. With frequent case-manager visits, he was able to follow the written directions. PA1 Example 6: A man with average intelligence receives financial counseling regarding budgeting, bill paying, managing his check book, and use of funds for leisure activities and life essentials. Despite agreed upon strategies and guidelines cuing geared to help the person live within his financial boundaries, he usually cashes pay checks immediately and spends seventy-five percent of his earnings despite bills, obligations, and other expenses which require attention. PA1 Example 7: A person with cognitive disabilities is taught how to greet guests who come to the door. However, once he introduces himself, asks the person's name, and says "pleased to meet you." he persists in going through the script long after it is applicable. (This behavior also may reflect impulsivity.) PA1 Example 8: A person living from a fixed income and budget goes food shopping. He brings his shopping list and the usual amount of money. While selecting items from this list he is approached by a promoter to purchase a manual food processor on a ten day, fully refundable trial. The person makes the purchase, is unable to complete the necessary food purchases and blames the independent living instructor for not having him bring sufficient funds. (ALSO, inadequate planning and self monitoring may also operate.) PA1 Example 9: A person applies for and interviews for a job. During the meeting, the applicant admonishes the interviewer for being late. When job duties are described the applicant complains that there is too much time required filling in as a receptionist. When the applicant did not notice the interviewer check and re-check his watch, cross his arms, and interrupt the applicant mid sentence when the applicant scorned the salary. Later when asked how the interview proceeded, the candidate disclaimed any interest in the job, saying that the salary and hours weren't worth it.
As these examples show, a person with executive dysfunction may outwardly appear to function with normal skills, but have dysfunctions which manifest during everyday routines. Diagnosing these dysfunctions is problematic for the very reason that they are often not observable from a typical lab testing situation. A person may function perfectly during analysis and review of activities. It is only when they are engaged in daily activities that these dysfunctions appear.
Attempting to determine executive dysfunctions from observing the person during daily situations is problematic. First, there is the time and expense of accompanying and observing the person during their daily routines. Such observation may take several days or weeks to readily determine a pattern of executive dsyfunctions. Further, the presence of the observer can affect the results, wherein the person will modify their behavior or take different actions because they know the observer is there. For dysfunctional persons attempting to autonomously function in the real world, the presence of an observer is a self-conscious reminder to behave "correctly", as well as a support as a person the dysfunctional individual can defer to for advice instead of making their own decisions.